IMPLANTATION OF FOREIGN BODIES into the subcutaneous tissue of the penis leads to a condition best defined as artificial penile nodules.1 It seems to be a frequent practice in the Far East and in Southeast Asia.2–5 Genitourinary physicians must be familiar with this practice, because it should not be mistaken for other pathologic conditions3 and it provides insight into different sexual cultures.
Based on a case report of artificial penile nodules, we report on a practice that is still performed in the area of Bandung, the capital of West Java, Indonesia.
A promiscuous, unmarried 26-year-old Indonesian man presented to private practice (T.S.D.) for fear of a sexually transmitted disease (STD); he was circumcised and had two nodules in the subcutaneous tissue of the shaft of the penis. At examination, the nodules were located on the anterior and ventral part of the shaft, and measured 1.4 cm × 0.5 cm and 1.2 cm × 0.4 cm, respectively (Figure 1). The overlying skin was normal. On palpation, the nodules were hard, nontender, and moved freely. Tattoos were also noted on the patient's chest and arms. No other clinical abnormalities were found. Laboratory tests for STD were negative for syphilis, gonorrhea, and chlamydial infection. The patient refused HIV screening.
Further questioning revealed that a friend had implanted the foreign bodies while they were imprisoned 3 years before, and that the practice was widespread among prison inmates. He also used to implant these foreign bodies to his friends. After washing the skin of the penis with soap and hot water, the skin was pierced by the sharpened end of a tooth brush. The foreign bodies were also made from parts of a toothbrush, and the sharp edges were polished, resulting in a nearly oval shape (Figure 2). The foreign bodies were pushed with the sharpened toothbrush through the wound into the subcutaneous tissue. To prevent or to stop bleeding, coffee powder was applied onto the wound, which usually healed within 1 week. The patient mentioned that only 1 of 10 implantations show secondary infection that require medical help.
Foreign bodies are implanted in the shaft of the penis, and eventually in the prepuce in the uncircumcised, to augment excitation and sexual pleasure of the female partner during sexual intercourse. In some cases, the practice is associated with psychosexual problems such as impotence,1,5 but in general it is performed by highly sexually active men. The practice is still common in Indonesia and in other countries of Southeast Asia. The practice was already described in Indonesia by an anthropologist more than 100 years ago among the Batak tribe in Sumatra and the Alfuros in North Sulawesi.6 It is clear that this is a traditional longstanding practice, and the claim that it began in Thailand after World War II is most likely incorrect.3 The practice seems to be absent in the Western industrialized countries; it has been described in other areas such as Argentina,7 in prisoners in Rumania,8 and in Israel (in 0.6% of Jewish immigrants from Russia).9
The implants are now most often made of glass or plastic, but other materials have been described (e.g., bullets, beads, jewels, pearls, paddies, grains of rice).1–3 The artificial nodules are known as “chagan ball” in Korea, “bulleetus” in the Philippines and “Tancho nodules” in Thailand.
The practice seems particularly widespread in prison settings among poor, sexually promiscuous individuals. The purpose is to enhance sexual sensation for female sex partners. Penile nodules are not related to homosexual anal intercourse in the prison setting; although severely reprimanded and punished anal intercourse occurs in prisons in West Java. Our patient admitted to practicing insertive anal sex in prison, but mentioned that it became painful with the implants.
Inside and outside of prisons, the foreign bodies are generally implanted by nonmedical personnel (e.g., a friend, by the individual himself). Use of razor blades for incision of the skin was reported, but this practice was quickly abandoned because it caused profuse bleeding. The wounds usually heal spontaneously, but secondary infection8 and foreign body granuloma may occur.3 The practice carries some risk of transmission of HIV, which now is highly prevalent in high-risk populations of Southeast Asia. This is not yet the case in Indonesia, where HIV has just begun to spread10; however, this situation could deteriorate rapidly, and prisoners are among the sentinel populations to monitor.
The diagnosis of artificial penile nodules is usually straightforward, and the stony hardness of the implanted foreign body is characteristic of the condition. However, other conditions such as sclerosing lipogranuloma, paraffinoma, silicone granuloma, cyst, mucocele, and penile nodule due to subcutaneous angiitis may require differentiation from artificial penile nodules.1
It is not known how widespread the practice of penile implants is; the artificial nodules are usually identified incidentally when a patient consults for a concomitant STD, or more rarely for superinfection. In the majority of cases, the implants do not cause symptoms or create discomfort and should not be extracted, although extraction was recommended by some venerologists.
The anthropological aspects of these “genital artifacts” have rarely been discussed. They seem to indicate that increasing sexual pleasure for the partner is emphasized in the sexual culture of many populations (e.g., Southeast Asia). It is the task of sexual anthropologists to study this practice more in-depth.
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10. Ieven M, Idajadi A, Rosana Y, et al, for the RI-EC AIDS Project. HIV: still not a major problem in commercial sex workers (CSW) in Java, Indonesia (abstract no. I-13). Paper presented at: the 37th ICAAC Conference. Toronto, 1997.